Please fill in all fields marked with a *
	Membership Type	Full Associate Lifetime *
	Application Type	New Renewal *
	Last Name
	First Name
	Address
	Address 2
	City
	State
	ZIP (nnnnn or nnnnn-nnnn)
	Phone (nnn-nnn-nnnn)
	Cell Phone (nnn-nnn-nnnn)
	Do you play golf?
	Profession
	Adjuster License No.
	License Exp. Date (mm/yyyy)
	Company Type
	Do you derive the majority of your income from claims work?	Yes No
	Employer
	Employer Address
	Employer Address 2
	Employer City
	Employer State
	Employer ZIP (nnnnn or nnnnn-nnnn)
	Employer FAX (nnn-nnn-nnnn)
	Employer Toll Free Phone (nnn-nnn-nnnn)
	E-mail